Reproductive health in rural Malawi: a population-based survey.

OBJECTIVES: To assess pregnancy outcome, maternal mortality and health-seeking behaviour in a rural African population and to assess the effects on these of women's education, distance from a health centre and household type. DESIGN: Descriptive population-based study. SETTING: A rural community in southern Malawi. POPULATION: All women living in the catchment area of a rural health centre. METHODS: Interviews with women in 20,649 households using structured questionnaires. MAIN OUTCOME MEASURES: Pregnancy outcome, the effect of women's education, distance from a health centre and household type on pregnancy outcome, maternal morbidity and estimates of maternal and perinatal mortality. RESULTS: Educational level was lower for women than for men. A significant association was found between educational level and fertility. Women aged 45-49 reported an average of six pregnancies with four resulting in currently living children. Successful pregnancy outcome was more likely with increased education and if the woman lived closer to the health centre. Despite living an average of 5 km from the health centre, over 90% of women attended antenatal clinic with a mean of five visits. Assistance at delivery by a trained health care worker was more likely as education increased and was less likely as distance from the health centre increased. Maternal mortality was reported at 413 per 100,000 deliveries (95% CI 144-682). The perinatal mortality rate in this population was estimated at 30 per 1000. An increased perinatal mortality was noted for women who were delivered by a female relative. Perinatal mortality rates were similar for delivery by a traditional birth attendant or a trained nurse-midwife. Education and proximity to the health centre were both associated with improved outcome. CONCLUSIONS: Many women in this rural community suffer the consequences of high pregnancy loss. Maternal and perinatal mortality are high. Improved education and skilled assistance at delivery can result in improved pregnancy outcome. Proximity of any household to a health centre has an effect on outcomes.

The impact of malarial infection and diet on the anaemia status of rural pregnant Malawian women.

OBJECTIVE: To investigate haematological and biochemical iron indices in relation to malaria, gravida, and dietary iron status in rural pregnant Malawian women. DESIGN: In this self-selected sample, haemoglobin, haematocrit, red cell indices, serum ferritin, serum iron, serum transferrin, and serum transferrin receptor (TfR) were measured. Infection was assessed by a malaria slide, serum C-reactive protein, and white blood cell count. Dietary iron variables were measured by three 24-h interactive recalls. SETTING AND SUBJECTS: 152 rural pregnant women recruited at 24 weeks gestation while attending a rural antenatal clinic in Southern Malawi; 36% were primagravid; 43% were gravida 2-4; 26% were gravida >5. RESULTS: Of the women, 69% (n=105) were anaemic (haemoglobin <110 g/l); 37% (n=39) had anaemia and malarial parasitaemia on the test day; 17% (n=26) with malaria were also classified with iron deficiency (ID) anaemia (based on serum ferritin < or = 50 microg/l and Hb <110 g/l) while an additional seven with malaria were classified with ID without anaemia. In malarial-free subjects, 32% were classified with IDA (serum ferritin <12 microg/l and Hb <110 g/l) and 17% with ID (serum ferritin <12 microg/l; Hb > or = 110 g/l). Serum TfR concentrations were elevated in anaemic women (P<0.01). In non-malarial parasitaemic subjects, serum TfR correlated negatively with haemoglobin (r=-0.313; P<0.001) but not serum ferritin. Of the women, 49% were at risk for inadequate iron intakes. Most dietary iron was non-haem; plant foods provided 89%; flesh foods (mainly fish) only 9%. Malarial parasitaemia and intakes of available iron impacted significantly on iron status. CONCLUSION: Anaemia prevalence from all causes was high (that is, 69%); three factors were implicated: malaria, and deficiencies of iron and possibly folate, induced partly by an inadequate dietary supply and/or secondary to malarial parasitaemia. SPONSORSHIP: International Development Research Centre (IDRC) of Canada. Opportunities for Micronutrient Interventions (OMNI) Project. Natural Sciences and Engineering Research Council of Canada.

Packaged treatment for first-line care in cerebral malaria and meningitis.

Described are the results of a trial carried out from January to June 1996 in southern Malawi to determine the effectiveness of a treatment pack for infants and children under the age of 6 years, who presented as emergencies to rural health centres with presumptive diagnoses of severe/cerebral malaria or meningitis. Each complete treatment pack (approximate cost, US$ 6) contained, inter alia, intramuscular quinine, intramuscular choloramphenicol, dextrose, paraldehyde, a nasogastric tube, prepacked syringes, and sterile water. A modified coma score and drug dosage nomogram were also included in the package. Despite a considerable drop in overall mortality, problems arose with regard to the incomplete treatment of possible meningitis and in the development of a rational referral policy.

PIP: The majority of infants and young children in Malawi receive their medical care from rural health centers that are minimally equipped for emergencies and lack laboratory facilities. A pilot project conducted in southern Malawi's Mangochi District in December-June 1996 assessed the effectiveness of a treatment pack for children under 6 years of age who presented to rural health centers with presumptive diagnoses of severe/cerebral malaria or meningitis. Each pack (cost, US$6) contained intramuscular quinine and chloramphenicol, dextrose, paraldehyde, a nasogastric tube, prepackaged syringes, sterile water, a modified coma score, and a drug dosage nomogram. Records for 64 infants and children admitted to 10 health centers with malaria or meningitis in the 6 months preceding the trial (July-December 1995) were compared with those for 96 infants and children who presented to 19 centers during the study period with these diagnoses. Only 63% of children in the latter group received the full treatment outlined in the study protocol. 52% of children in the pretrial group and 31% of those in the intervention group were completely treated in the health center; the remainder were referred for hospital care. The case fatality rate was 51% in the pretrial period and 23% in the trial phase--a rate comparable to that obtained in hospital settings. Most children died awaiting transport to the hospital. Of concern are difficulties differentiating between meningitis and severe or cerebral malaria at the health center level. The estimated cost of each life saved at the health center was $29 compared with $30 when cases were transferred by ambulance to the hospital. Further controlled studies are needed to determine whether these treatment packs can be used routinely at the periphery.

Is zinc a limiting nutrient in the diets of rural pregnant Malawian women?

Pregnant women consuming plant-based diets are at risk of Zn deficiency; Zn requirements for fetal growth and maternal tissue accretion are high. Therefore we have studied, at 24 and 33 weeks gestation, the Zn status of eighty-seven pregnant rural Malawian women (mean age 22.7 years) who consume maize-based diets, using anthropometry, dietary intake data, plasma and hair Zn concentrations, and infection status via serum C-reactive protein, leucocyte count, and malaria blood smear. Of the women, 12% were stunted (height-for-age Z score < -2 SD) and 20% lost weight over the 9-week period; weight gain averaged 0.13 kg/week. Mean plasma Zn concentration declined significantly from 24 to 33 weeks (7.9 (SD 2.2) v. 6.6 (SD 2.0) mumol/l; P < 0.0003). Both plasma and hair Zn values were very low; nearly 50% of the women had both plasma and hair Zn values below acceptable cut-off values. No significant differences in biochemical Zn indices existed between those who tested positive and negative for infection. Cereals (mainly maize) provided more than two-thirds of mean energy intake compared with less than 5% from flesh foods. As a result about 60% of the subjects had dietary phytate:Zn molar ratios greater than 15, and more than 35% had inadequate Zn intakes based on probability estimates and WHO basal requirements. Biochemical evidence of Zn deficiency was attributed in part to low intakes of poorly available Zn. The anthropometric, biochemical, and dietary data together indicate that Zn deficiency may be a factor limiting pregnancy outcome in rural Malawian women.

An interactive 24-h recall technique for assessing the adequacy of trace mineral intakes of rural Malawian women; its advantages and limitations.

OBJECTIVES: To assess the relative validity of an interactive 24-h recall for estimating mineral intakes of rural Malawian women. DESIGN: Repeated interactive 24-h recalls were compared with weighed records collected for the same 2 days of food intake, and for 2 days 1-2 weeks prior and subsequent to the weighed record data collection period. SETTING: Three villages in traditional authority Jalasi, Mangochi District, Malawi. SUBJECTS: 60 rural pregnant women. RESULTS: Median daily intakes of most minerals (Ca, Fe, Zn, Mn) were comparable for the two methods, but slightly overestimated for recalled (R) intakes expressed per MJ (mg/MJ) compared to weighed (W) (R vs W = Ca, 48 vs 38; Fe, 2.1 vs 1.9; Zn, 0.9 vs 0.8; Mn, 0.40 vs 0.38; P < or = 0.05). By contrast, recalled median daily intakes of energy (kJ), protein (g) fat (g) and Cu (mg) were slightly underestimated (R vs W = 6588 vs 7824; 51 vs 57; 14 vs 15; 1.3 vs 1.6, respectively; P < or = 0.05). Discrepancies were attributed primarily to inaccurate estimates of main meal food portions [R vs W = nsima (the main meal cereal style) 475 vs 557; and legume relish 171 vs 118 P < or = 0.001]. For classifying intakes into tertiles, agreement between the two methods was poor for daily intakes (Cohen's kappa < 0.40), but fair when expressed per MJ, and as a percentage of energy from food groups (Cohen's kappa > or = 0.40). Variance ratios for recall data were higher than corresponding ratios for the weighed intakes (R vs W = for energy, 4.87 vs 0.87), indicating poorer recall measurement precision. CONCLUSION: Results emphasise the importance of selecting the dietary method according to the study objectives, and the nutrients required.

Cataracts and cigarette smoking. The City Eye Study.

The City Eye Study is a nine year longitudinal prospective epidemiological study. During the first three year phase the study recruited 1029 volunteers, aged between 54 and 65 years, primarily from companies and organisations working in or around the City of London. The analysis of the first cohort data shows a significant association between nuclear lens opacities and moderate to heavy cigarette smoking. The Relative Risk for nuclear lens opacity and cigarette smoking ranges from 1.0 for past light-smokers through 2.6 for past heavy-smokers, to 2.9 for present heavy smokers.

Middle ear disease assessed by impedance in primary school children in south London.

413 children aged 5 to 6 years from twelve randomly selected primary schools in SE London were screened for middle ear disease by the use of tympanography . Those with abnormal tympanograms were retested 10 weeks later. 41% had an abnormality at first test, but half had recovered by second test. Children of African origin were significantly less likely to show abnormalities and in almost none did the abnormality persist; children from poorer families were significantly more likely to have a persistent abnormality. Tympanography is a feasible screening test in children of this age-group and complements audiometry and otoscopy.

Diabetic retinopathy and visual disability.

Data from blind and partial sight registers and from special surveys have been analysed to derive estimates of the number of adults in England and Wales visually disabled by diabetic retinopathy. If visual disability is defined as 'less than 6/18 Snellen', approximately 30 per 100.000 adults living at home are disabled by diabetic retinopathy; if defined around traditional concepts of 'blindness' (approximately 3/60 vision or less) the estimated figure is about 20 per 100.000 total population. Annual additions to the blind register for diabetic retinopathy are about two per 100.000 total population. Weaknesses in data gathering are discussed.

Visual disability and home lighting.

13 men and 43 women (average age 76) attending a low-vision clinic with visual acuity of 6/18 (Snellen) or less had acuity measurements made under standard (measured) hospital conditions, under normal home conditions, and under home conditions with augmented lighting. Median levels of ambient lighting in the home were 1/10 of those in hospital, while levels for reading were 1/7. Augmented lighting at home (a 60 watt bulb in a small adjustable lamp) improved visual acuity in 82% of subjects, restoring all but 11% to the levels achieved in hospital or above. Improvement was unrelated to disease. General levels of lighting are often so poor in the homes of elderly people that the number of people functioning as "blind" is twice what it need be. Simple improvements to lighting would reduce the prevalence of "visual disability" (less than 6/18 Snellen) from 520/100,000 home-based adults to about 300.

Visual acuity at home and in eye clinics.

Most elderly visually disabled people have lower levels of visual acuity for both reading and getting about in their homes than would be inferred from clinic measurements. Even with optimum optical correction, performance can be much improved by simple modifications to existing facilities, individual advice, and in most cases the addition of a simple adjustable reading lamp.